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					Abnormal Bleeding in
Pregnancy and Labour
         Dr. Chitra Setya
                           MD
    Sr. Consultant Obstetrician and
  Gynaecologist, Apollo Hospital Noida
Definition

Antepartum haemorrhage---It is
 bleeding from the genital tract after the
 28th week of pregnancy and before the end
 of the second stage of labour .


Postpartum haemorrhage–
 haemorrhage following delivery.
Antepartum Bleeding
Causes
• Abruptio Placentae
• Placenta praevia
• Rupture of uterus
• Carcinoma of cervix
• Trauma
• Cervical polyp
• Unknown origin
Placenta praevia

• Definition : The placenta is
  partially or totally attached to
  the lower uterine segment.
• Incidence : 0.5% , more
  common in multiparas and in
  twin pregnancy due to the large
  size of the placenta.
Placenta praevia

Types:
     1. Total : internal os
 completely covered.
     2. Partial : internal os
 partially covered
     3. Marginal : edge of
 placenta at the margin of int. os
     4. Low lying placenta
Placenta praevia
Placenta praevia
Placenta praevia

Risk factors
• Chronic hypertension
• Multiparity (second or succeeding
  pregnancy)
• Multiple gestations (i.e., twins, etc.)
• Older maternal age
• Previous cesarean delivery
• Tobacco use
• Prior uterine curettage (D&C)
Placenta praevia
Diagnosis
 Symptoms:
  • Causeless, painless and recurrent
    bright-red vaginal bleeding;
  • It is causeless, but may follow sexual
    intercourse or vaginal examination.
  • It is painless, but may be associated
    with labour pains .
  • It is recurrent, but may occur once in
    slight placenta praevia lateralis.
Placenta praevia

Signs:
  • General examination:
      Depends on extent of blood loss
  • Abdominal examination:
     • The uterus is corresponding to
       the period of amenorrhoea,
       relaxed and not tender.
Placenta praevia

  • The foetal parts and heart sound
    (FHS) can be easily detected.
  • Malpresentations, particularly
    transverse and oblique lie and
    breech presentation are more
    common as well as non-
    engagement of the head.
Placenta praevia

Treatment
At Home
• Arrange for immediate
  transfer to the hospital.
• No vaginal examination and
  no vaginal pack, only a
  sterile vulval pad is applied.
Placenta praevia

• No oral intake as anaesthesia
  may be required.
• Antishock measures as
  pethidine IM, fluids and blood
  transfusion may be given in the
  way to the hospital if bleeding
  is severe.
Placenta praevia

At Hospital
• Assessment of the patient's
  condition, general and abdominal
  examination and resuscitation if
  needed.
• At least 2 units of cross matched
  blood should be available.
Placenta praevia

If the patient is not in labour
    • If the bleeding is severe,
      continue antishock measures
      and do immediate caesarean
      section .
    • If the bleeding is slight, look to
      the gestational age :
Placenta praevia
    − If completed 37 weeks (36 weeks
      by some authors) or more,
      pregnancy is terminated by
      induction of labour or caesarean
      section
    − If less than 37 weeks (36 weeks by
      others), conservative treatment is
      indicated till the end of 37 (or 36)
      weeks but not more.
Placenta praevia
 Conservative treatment:
   • The patient is kept hospitalized
     with bed rest and observation till
     delivery.
   • Anaemia should be corrected if
     present.
   • Observation of foetal wellbeing.
   • Anti-D immunoglobulin is given
     for the Rh-negative mother.
Placenta praevia

If the patient is in labour:
   • Vaginal examination is done
     using precautions. According
     to the findings, the patient will
     be delivered either vaginally
     or by caesarean section.
Placenta praevia
 Vaginal delivery is allowed if the
 following findings are fulfilled:
   • Placenta praevia is lateralis or
     marginalis anterior,
   • bleeding is slight,
   • vertex presentation,
   • adequate pelvis with no soft tissue
     obstruction.
Caesarian section--- normal mode of
delivery
Placenta praevia

Complications of Placenta Praevia
• Maternal: mortality rate: 0.2%.
• Foetal:
   • Foetal mortality rate is 20 %.
   • Prematurity.
   • Asphyxia.
   • Malformations (2%).
Abruptio placenta
 Placental abruption is the premature
  separation of a normally-implanted placenta
  from the uterine wall.
Risk factors :
• Older maternal age
• Hypertension (high blood pressure)
• Tobacco, cocaine, or methamphetamine use
• Clotting abnormalities
• Abdominal trauma
• Previous placental abruption
• Uterine fibroids
Abruptio placenta
Signs and symptoms of placental
  abruption:
• Vaginal bleeding
• Sudden onset of labor, with
  persistent pain between
  contractions
• Tenderness over uterus
• Back pain
• Signs of shock if blood loss is
  significant
Abruptio placenta

 Management -- Depends on gestational
 age and status of mother & fetus
  - live& mature fetus– immediate caesarian
 section with fluid & blood replacement
  - maternal condition stable with premature
 fetus – expectant management under close
 supervision
  - severe placental abruption with a dead
 fetus – vaginal delivery preferred
Antepartum bleeding

•   Rupture of uterus
•   Carcinoma of cervix
•   Trauma
•   Cervical polyp
•   Unknown origin
Post partum haemorrhage

Defined as the loss of 500ml or more
 of blood after completion of the third
 stage of labour
Causes:
   -- Uterine atony
   -- Retained placenta
   -- Genital lacerations- vaginal,
      cervical tears
Post partum haemorrhage

Uterine atony : Causes
    Large infant, forceps delivery, intrauterine
    manipulation, use of anaesthetic agents,
    multiple fetuses.
Treatment:
•     Manual removal of the placenta
•     Oxytocin- 20 units in 1000ml fluid IV
•     Methylergonovine 0.2 mg IM
•     Prostaglandins 0.25mg IM
Post partum haemorrhage
Retained placenta > 30 minutes seen in
    ~ 6% of deliveries.
•   Risk increased with: prior C/S, curettage ,
    uterine infection, increased parity.
•   Most patients have no risk factors.
•   Occasionally succenturiate lobe left
    behind.
•   Attempt to remove the placenta by usual
    methods.
•   Excess traction on cord may cause cord
    tear or uterine inversion.
Post partum haemorrhage

Birth trauma
• Vaginal, cervical tears --- to be
  repaired
• Hematoma --- drain
Absent fetal movements

         Dr. Chitra Setya
                           MD
    Sr. Consultant Obstetrician and
  Gynaecologist, Apollo Hospital Noida
Fetal Movements
   First fetal movement occurs around 8-9
    weeks
   For primiparas fetal movement often not felt
    till 18wks or later
   For multiparas fetal movement is felt around
    15 –16 wks
   Simplest and oldest form of fetal welfare
    assessment
Fetal movements
Procedure:
   The test is valid after 30 weeks of pregnancy.

   The mother counts the fetal movements in 3
    hours during the period of 12 hours e.g. from
    9 am to 9 p.m , - The count is multiplied by 4
    to get the fetal movements in 12 hours. If
    count < 10 – further testing
Fetal movements
   Count-to -ten Cardiff system : 10
    movements in 12 hrs
   Cessation of the fetal movement 12-24
    hours before stoppage of the heart ---
    "movement alarm signal".
Fetal movements
Advantages:
- Informativeand non-invasive.
- Pregnant woman can monitor herself.
- No cost.
- Accurate gestational age not required.
Fetal movements
Drawbacks:
- Awareness of the fetal movement differs from
  mother to mother.
- Cessation of fetal movement may occur due to
  intrauterine sleep.
- Sedation of the fetus occurs if mother is on sedatives.
- Sudden death of the fetus may occur without
  preceding slowing of the fetal movement as in
  abruptio placenta or it may be preceded by increased
  flurry movements.
Fetal movements
Assessment of fetal activity

1.   Maternal perception
2.   Tocodynamometer
3.   Ultrasound
    Fetuses have sleep- activity cycles with sleep
     cycles extending upto 23 min.
    Activity decreases with decreased amniotic fluid
     volume
Fetal movements
Electronic monitoring
Non Stress test

Done with 2 transducers placed to assess fetal heart
and uterine contractions
Fetal movements
Fetal movements
NST
Reactive test:
  Two or more fetal movements are
 accompanied by acceleration of FHR of 15
 beats/ minute for at least 15 seconds’
 duration. Reactive test means that the fetus
 can survive for one week, so the test should
 be repeated weekly.
Non -reactive test:
  No FHR acceleration in response to fetal
 movements so contraction stress test is
 indicated.
Fetal movements
Ultrasound Doppler monitoring
Check the FHR, Fetal movements and the
 blood flow to the uterus and the baby

Pregnancy outcome
Pregnancy outcome was the same for mothers
  who measured fetal movements and those
  who did not but it is still considered good for
  early detection of fetal well being as well for
  mother– baby bonding
Fetal Movements
ACOG recommendations
Daily fetal kick count to be maintained in
the 3rd trimester
Notify the health provider if the count is
decreased
Fetal Movements
Summary
- Fetal movement record is a simple ,harmless
  & cost effective way to assess fetal well –
  being
- Pregnancies with decreased fetal movements
  are at an increased risk of adverse pregnancy
  outcome
- It also helps in “Bonding” between the mother
  and fetus
Premature rupture of
    membranes
        Dr. Chitra Setya
                         MD
  Sr. Consultant Obstetrician and
Gynaecologist, Apollo Hospital Noida
 Premature rupture of membranes
Rupture of membranes before the onset of labour
at any stage of gestation

Occurs in 3% of all pregnancies

Responsible for 1/3rd causes of preterm birth

Causes significant fetal complications– sepsis,
prematurity, cord prolapse, abruptio placenta, fetal
death
 Premature rupture of membranes
Risk Factors
  Lower socioeconomic class
  Previous preterm birth
  H/O STD
  Multiple pregnancy
  Polyhydramnios
  Procedures– cervical
  encirclage,amniocentesis
 Premature rupture of membranes
Diagnosis
  History
  Examination
  Vaginal swab
  Ultrasound assessment
          - amniotic fluid
          - fetal assessment
 Premature rupture of membranes


Treatment --- depends on
       - gestational age,
       - amount of amniotic fluid
       - fetal state
       - infection
 Premature rupture of membranes
Expectant management
Antibiotic therapy -- Ampicillin with Metronidazole
Corticosteroid therapy- to accelerate lung maturity
   Betamethasone 12mg I/M 24hrs apart –2 doses
   Dexamethasone 5mg 12 hrly - 4 doses
Tocolytics- to delay onset of labour
Risks
Maternal risks– infection
Fetal risks– pulmonary hypoplasia, limb
abnormalities,infection
 Premature rupture of membranes
Summary of treatment
              History, examination, USG

24 – 31 wks           32 – 33 wks         34 – 36 wks

Bed rest              Bed rest            Antibiotics
Antibiotics           Antibiotics         Deliver
Steroids              Steroids
Deliver 34 wks        Deliver 34 wks
 Premature rupture of membranes
Complications
 Delivery within one week
 Respiratory distress syndrome
 Cord compression
 Cord prolapse
 Chorioamnionitis
 Abruptio placentae
 Antepartum fetal death
 Molar Pregnancy
        Dr. Chitra Setya
                         MD
  Sr. Consultant Obstetrician and
Gynaecologist, Apollo Hospital Noida
              Molar Pregnancy
Definition and Etiology
   Hydatidiform mole is a pregnancy characterized
    by vesicular swelling of placental villi and usually
    the absence of an intact fetus.
   The etiology -- unclear, but appears to be due to
    abnormal gametogenesis and fertilization
   Incidence-- 1 out of 500-600
            Molar Pregnancy

Risk factors
 1. Maternal age > 40 years
                < 15 years
 2. Paternal age > 45 years

 3. Previous hydatidiform mole 1st: 1% , 2nd 15-28%
 4. Vitamin A deficiency
 5. Consanguinous marriages
 6. Previous spontaneous abortion
 7. More common in orients
            Molar Pregnancy
Molar pregnancy - Complete
                     - Partial
Complete mole - Mass of tissue is completely
  made up of abnormal cells
 There is no fetus and nothing can be found at the
  time of the first scan.
Partial mole - Mass may contain both these
  abnormal cells and often a fetus that has severe
  defects.
               Molar Pregnancy
History
Amenorrhoea
Vaginal bleeding
Excessive nausea & vomiting
Passage of vesicles
Examination
Uterine size> period of pregnancy
Soft boggy feel of uterus- with no fetal parts felt
Signs of anaemia
              Molar Pregnancy
Diagnosis of hydatidiform mole

   Quantitative beta-HCG – value > 10,000mIU/ml

   Ultrasound is the standard criterion for
    identifying both complete and partial molar
    pregnancies. The classic image is of a
    “snowstorm” pattern
            Molar Pregnancy
Signs and Symptoms of Complete
Hydatidiform Mole
 Vaginal bleeding

 Hyperemesis ( severe vomiting)

 Size inconsistent with gestational age( with no

  fetal heart beating and fetal movement)
 Preeclampsia

 Theca lutein ovarian cysts
             Molar Pregnancy
Signs and Symptoms of Partial Hydatidiform
Mole

     Vaginal bleeding
     Absence of fetal heart tones
     Uterine enlargement and preeclampsia is
      reported in only 3% of patients.
     Theca lutein cysts, hyperemesis is rare.
             Molar Pregnancy
Differential diagnosis

     Abortion
     Multiple pregnancy
     Polyhydramnios
             Molar Pregnancy
Treatment

Suction dilation and curettage :
 Complete evacuation of the uterus

 USG to confirm complete evacuation

 Serum β-HCG weekly till undetectable & monthly for 6
  months
 Serum β- HCG expected to be undetectable by8-12 wks

 Advise contraception till then– condoms, OC pills after
  HCG negative
             Molar Pregnancy
Indications for chemotherapy
   Serum B-HCG >20,000IU/L or urinary B-HCG >
    30,000 IU/L 4 wks post evacuation
   Rising level of B- HCG anytime post evacuation
   Positive B-HCG levels 6 mths post evacuation
   Evidence of metastasis
   Persistant vaginal bleeding with +ve B- HCG
   Methotrexate is the drug used
                 RCOG Recommendations


1.   Ultrasound has limited value in detecting partial molar pregnancies.
2.   In twin pregnancies with a viable fetus and a molar pregnancy, the
     pregnancy can be allowed to proceed.
3.   Surgical evacuation of molar pregnancies is advisable.
4.   Routine repeat evacuation after the diagnosis of a molar pregnancy is
     not warranted.
5.   Registration of any molar pregnancy is essential.
6.   The combined oral contraceptive pill and hormone replacement therapy
     are safe to use after hCG levels have reverted to normal.
7.   Women should be advised not to conceive until the hCG level has been
     normal for six months or follow-up has been completed (whichever is
     the sooner).


                                         Grade C recommendation

				
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